How do you manage noradrenaline infusions

8/6/04

Dear all,
I would appreciate any feedback regarding how units set up and run their high dose inotrope infusions (esp noradrenaline), and how a change of syringe is accomplished (or safety measures to ensure burettes don't run dry) without compromising fragile haemodynamics.
If you have the time, an email response would be great or voicemail may be
left on (02) 9828 - 3627.
I'll collate responses for future reference in case anyone wants access to
replies not posted to the list.

With many thanks - in advance!

CNC Tertiary Referral ICU Metropolitan

9/6/04
We grappled with this issue some years ago when we were struggling with the vagaries of syringe drivers.  We made the decision to only use Gemini pumps for the following reasons;
1.  the flow pattern of the pump ensuring a continuous infusion of inotrope
2.  you could keep the pump running whilst you changed the bag. 
3.  the rn ensures that there is a replacement bag hanging for the next bag change.
We don't use inline burettes because of the possible chance of getting the concentration wrong.
Our infusions are all based on concentrations of 6mg in 100mls saline, moving up the concentration gradient.  eg 12 mg in 100mls, 24mgs in 100mls etc, as required
We don't worry about taking fluid out because is was felt that knowing exactly how may mg or micrograms per min or per min per kg per hr was irrelevant because you are titrating the drug against an effect.  eg map or cpp
On the whole we rarely have problems with this method of running noradrenalin and adrenaline infusions.  And its simplicity makes educating new and junior staff members much easier.

Data Manager
CNC Tertiary Referral ICU Metropolitan

9/6/04

we run ours via the old Gemini pumps because unlike the Baxter pump you can key in the new volume to be infused without having to stop the pump.  We don't run inotropes via burettes but load them in 100 ml bags and just simply spike the new bag without stopping the current infusion.

CNC 2 Tertiary Referral ICU Metropolitan

9/6/04

XXX private has also switched to the Gemini system for the advantages that the others have listed. We use syringes though for the  delivery of the inotrope. This is only acceptable for those lower rates were  the backup syringe can be changed simply and quickly.
Our inotropes are all drawn up according to the patients weight. This enables the staff to know that 1ml/hr of noradrenaline is running at  0.01mcg/kg/min. This is a computer program that we have on our nurses station at the staff just put in the patients weight and the computer spits out any inotrope you want.

Nurse Unit Manager Intensive Care Unit Private (Metropolitan)

9/6/04

Here we load a 100ml bag with 4mgs of noradrenalin as a single strength Infusion and run it through the gemini pumps. We have no problems with this for the same reasons that have already been mentioned. Hope this helps.

CNE ICU
Tertiary Referral ICU Metropolitan

9/6/04

I've never known where this 4mg / 100ml concentration (which is commonly used) came from.

If you do 6 mg / 100ml then 1 ml/hr = 1 mcg/min.

If you do 0.6 mg/kg in 100ml (or 0.3 mg/kg in 50 ml) then 1 ml/hr = 0.1 mcg/kg/min.

So where does 4mg / 100 ml come from?

Staff Specialist 9/6/04

Tertiary Referral ICU Metropolitan

10/6/04

here we have a weight based sticker system(Huh???)for drawing up drugs and run controlled infusions by syringe driver with a back up for double pumping during syringe change.
Pick up a sticker with the (estimated or actual) weight of the patient and draw up according to dilution so that 1ml/hr = 0.01mcg/kg/min (for norad/adrenaline) (1ml=2.5mcg/kg/min for dobutamine)
To increase the strength (usually for norad) we double the drug quantity so then 1ml= .02mcg/kg/min and so on.

Nurse Educator
Tertiary Referral ICU Metropolitan

10/6/04

dear all
I appreciate all the complicated methods you all have developed and work well within your units.   i feel that knowing exactly how many mcg / kg (for noradrenalin/adrenaline) the patient is receiving is largely anachronistic these days when we are titrating against an effect.  e.g. the order is titrate to MAPof X or CPP of y NOT increase by 1mcg/kg until map is X.  Also bringing weight into the picture also introduces another level of possible error especially how heavy is the patient anyway?

Data Manager
CNC Tertiary Referral ICU Metropolitan

10/6/04

Unlike the previous replies, we at the XXX (and throughout the Area Health) use syringe drivers.
We start with "single strength" 2mgNorAd in N/S to 50mls. As the demand increases we double and them quadruple the strength (8mg in 50mls). As one syringe gets close to empty, it alarms and a second driver is started at the same rate so there is a period of overlap.

Staff Specialist Intensive Care
Level 5 (JFICM 2) Greater Metropolitan

14/6/04

When I was working at the Austin in Melb, inotropes were all given via a syringe driver (50 ml).  Adrenaline came in 1mg amps so it was made up  as 3mg/50ml (1ml/hr = 1mcg/min).  Noradrenaline however, came in 2mg amps ... so instead of wasting it, it was made up as 4mg/50ml.

The 4mg/100ml seen in many places in Sydney may be a result of this earlier practice .. applied to the newer volumetric pumps.

In the enlightened altitude of Hornsby we use 6mg/100ml for noradrenaline.  We haven't used adrenaline since re-educating our Alfred hospital (Melb) trained registrar in January.

Codirector Level 5 (JFICM 2) Metropolitan ICU

15/6/2004

Isn't somebody studying this at present (Adr vs NorAdr in sepsis?)

Director of Intensive Care Level 5 Rural

16/6/04

The St George Hospital ICU is conducting "the Cat study", a double blind randomised trial to compare the clinical effects of adrenaline and noradrenaline in critically ill patients with circulatory failure.  Patients are stratified into 2 groups, circulatory failure due to sepsis syndrome/ septic shock, and circulatory failure due to primary cardiac causes, eg cardiogenic shock, normovolemia hypotension.  The bags are prepared on the 6 mg / 100ml principle (i.e. 1 ml/hr = 1 mcg/min).
Critical Care Coordinator

27/8/2004
Summary of responses from survey.
NORADRENALINE: Information sought on delivery of noradrenaline and change of 'bag' information -ICUConnect responses.
In summary:
*        5 hospitals use syringe drivers - 4 of these hospitals appear to double pump for an overlap during change of syringe.
*        5 hospitals use Gemini pumps
*        1 hospital; each uses Baxter, Braun, Alaris, IMED and Abbott, 6 did not state which pump brand they used.
*        2 hospitals use 1 pump and a Y - split with 2 bags attached
*        4 hospitals use 1 pump (100mL) and are able to change the bag without interruption to flow
*        3 hospitals use 1 pump and change the bag as fast as practicable
*        2 hospitals use a burette and top up the existing infusion
*        1 hospital uses 2 Gemini pumps and a 100mL bag: - does not appear a need for this as the Gemini allows flow to continue when changing bags

Since making a request for this information, we have been prompted to review the product information for Levophed (noradrenalin acid tartrate) produced by Abbott. It does not recommend the use solely of normal saline diluent. We have therefore changed our practice to using 100mL bags of 5% glucose per patient - which enables us to fill 2 syringes/single patient use. The bag is discarded at 24 hrs.

Once again, thank you to all the people (16 hospitals and 21 responses) who gave up their time to respond to me on this issue.